Can I start Eliquis (apixaban) if I suspect a patient has a Deep Vein Thrombosis (DVT)?

Starting Eliquis for Suspected DVT

You should NOT start Eliquis (apixaban) if you only suspect DVT—instead, initiate parenteral anticoagulation (LMWH, fondaparinux, or unfractionated heparin) while awaiting diagnostic confirmation, with the decision based on clinical suspicion level and time to testing. 1

Clinical Suspicion-Based Approach

The decision to anticoagulate before diagnostic confirmation depends on your pretest probability assessment and timing of diagnostic testing:

High Clinical Suspicion

• Start parenteral anticoagulation immediately while awaiting diagnostic test results 1
• Use LMWH (e.g., enoxaparin 1 mg/kg SC twice daily), fondaparinux, or unfractionated heparin 1
• The higher your clinical suspicion, the shorter the acceptable interval without treatment 1

Intermediate Clinical Suspicion

• Start parenteral anticoagulation if diagnostic testing will be delayed >4 hours 1
• If testing available within 4 hours, you may wait for results before initiating treatment 1

Low Clinical Suspicion

• Do NOT treat while awaiting results, provided testing is available within 24 hours 1
• The risk of bleeding in patients without VTE outweighs the benefit in this scenario 1

Why NOT Eliquis Initially?

Vitamin K antagonist therapy (and by extension DOACs like apixaban) should not be started before VTE has been confirmed 1. The guidelines explicitly state this principle because:

• Starting oral anticoagulation in patients who ultimately have DVT excluded is costly and burdensome 1
• Parenteral agents allow for rapid reversal if DVT is ruled out 1
• If you choose to give anticoagulation and testing will be completed within 12 hours, use a 12-hour dose (not 24-hour dose) of LMWH 1

When Eliquis IS Appropriate

Once DVT is objectively confirmed by diagnostic testing, apixaban becomes an excellent option:

• Apixaban is FDA-approved for treatment of DVT and can be started immediately after confirmation 2
• The 2021 CHEST guidelines give a strong recommendation for apixaban over warfarin for treatment-phase therapy (first 3 months) in confirmed VTE 1
• Apixaban eliminates the need for initial parenteral therapy overlap that warfarin requires 3, 4
• Dosing: 10 mg twice daily for 7 days, then 5 mg twice daily 2

Critical Pitfalls to Avoid

• Never start apixaban empirically before diagnostic confirmation unless you are treating it as confirmed DVT based on extremely high clinical suspicion where testing is impossible 1
• Do not assume all anticoagulants are interchangeable in the pre-diagnostic phase—parenteral agents are preferred for empiric treatment 1
• Assess bleeding risk factors (recent surgery, active bleeding) before starting any anticoagulation, as these contraindicate empiric treatment 1
• Consider poor cardiopulmonary reserve as a factor that may lower your threshold to treat empirically while awaiting testing 1

Special Populations

If cancer is present or suspected:

• The 2022 ITAC guidelines recommend apixaban can be used for initial treatment (first 10 days) in cancer patients with confirmed VTE and creatinine clearance ≥30 mL/min, but only if there is no high risk of GI or GU bleeding 1
• LMWH remains preferred in cancer-associated thrombosis for long-term treatment 1